Few seniors complain about medicare denials

By Susan Jaffe, Kaiser Health News

Posted:
12/18/2012 09:23:23 AM MST

Dan Driscoll used to be a smoker. During a regular doctor's visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, had the test done and was surprised when he got a bill from Medicare for $214.

Based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal.

Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor's visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.

Few seniors have the patience, tenacity or health to question a coverage denial, say advocates and counselors. And those who do appeal but lose on the first try tend to give up too soon, they say.

"People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up," said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. "Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad."

Medicare officials this year redesigned beneficiary statements to make instructions about the appeals process clearer, said an agency spokeswoman, who did not respond to requests for additional information.

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Some problems can be resolved without appealing, said Mary Ann Parker, an attorney with Washington's Long-Term Care Ombudsman Program, which advocates for nursing home residents.

Sometimes a payment is denied because the doctor or other provider used the wrong treatment or billing code. If the provider resubmits a corrected claim, it will most likely be paid.

Murphy said less than 10 percent of the several hundred denials that her organization handles each year for Connecticut residents are overturned in the first and second levels of appeals. "It's almost an automatic denial," she said.

But at the third level of appeal, the center has won roughly 60 percent of its appeals in the past three years. "If people knew that they are likely to lose at the first couple of levels, they would stick it out until they got to a judge," Murphy said.

"The administrative law judge stage is the first level when you can interact with a human," said Diane Paulson, senior attorney at Greater Boston Legal Services, which handles about 50 appeals a year. The first two levels of appeals are based on documents only.

Driscoll thought his case was a slam-dunk. Following instructions on his quarterly Medicare statement, he circled the charges he was questioning and sent it to the Medicare contractor's address listed on the notice. When he was turned down, he tried again, this time including a letter from his doctor saying that the aneurysm test was medically necessary. He attached pages from the "Medicare & You" handbook that say Medicare covers the test. "There was a lot of back-and-forth," he says, that required him to call his physician and the radiologist who performed the test to collect additional information.

His appeal was turned down again. Driscoll said he was unable to find out why. But that was enough for him.

"I paid the bill and I gave up," said Driscoll, who at the time was in the process of moving and retiring from his job at a nonprofit agency. He paid the $214 charge last year. "I spent over a year on this thing, and it wore me out."

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Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.